Authorization to Release/to Recieve Confidential Health Information

I understand that Unless revoked, this authorization is valid for 90 days from the signing date. I understand that I may revoke this authorization in writing at any time except to the extent disclosure has already been made in accordance with this document. Unless specifically excluded, this authorization includes release of specially active information requiring my explicit authorization for release this includes referral diagnosis and treatment information related to (please check to exclude)

Standby health information is protected by state and federal regulations to protect the confidentiality of this information and that my healthcare information may not be released or disclosed without my written authorization, unless otherwise provided for the law. I also understand that if I authorize a third-party that is not required to comply with such regulations to receive my healthcare information, my information may be redisclosed by the party and would no longer be protected. I understand that I do not have to sign this form as a condition for receiving treatment and I am entitled to a copy of my authorization form at any time of signing. I may call the medical records office at 8605330179 to inquire about revoking authorization. Not emergency release of records may take up to 30 working days emergency requests will be given prior to processing. Emergency status applies only to the release of records directly to another healthcare provider for urgent patient care. There is no charge to release records to another healthcare provider or to myself.